| Journal of Clinical and Analytical Medicine102

İzole Fibula Başı Dislokasyonu / Isolated Dislocation of the Head of the Fibula

İbrahim Arziman, Yavuz Katırcı, Serkan Bilgiç, Salim Kemal TuncerDepartment of Emergency Medicine Gülhane Military Medical Academy School of Medicine, Ankara, Turkey

Nadir Bir Dislokasyon: İzole Proksimal Tibiofibular Eklem Dislokasyonu

A Rare Dislocation: Isolated Proximal Tibiofibular Joint Dislocation

Corresponding Author: Serkan Bilgiç, GATA Ortopedi ve Travmatoloji AD, 06018, Ankara, Türkiye.GSM:+905052270148 E-mail: serbil11@gmail.com

Özetİzole proksimal tibiofibular eklem dislokasyonu, acil servislerde oldukça nadir karşılaşılan ve kolaylıkla atlanabilen travmalardan-dır. İnjuri mekanizması tam olarak açıklanmamış olmakla birlikte sıklıkla diz fleksiyonda iken plantar fleksiyondaki ayağın ani inver-siyonu ile eş zamanlı olarak meydana gelir. Tanı fizik muayenede sağlam tarafa kıyasla tibia proximalinde şişlik ve hassasiyetin tespit edilmesi ve radyolojik görüntüleme yöntemleri ile konur. Tedavi ise hala tartışmalı olup sıklıkla çoğu olguda konservatif yaklaşılmakta, seçilmiş olgularda cerrah stabilizasyona kadar gitmektedir. Burada bir futbolcunun izole proksimal tibiofibular eklem dislokasyonu olgusu sunmuş bulunmaktayız.

Anahtar KelimelerProksimal Tibiofibular Eklem, Fizik Muayene, Radyografi, Erken Tanı.

AbstractIsolated dislocation of proximal tibiofibular joint is one of the rarely encountered and easily overlooked traumas in ER departments. Injury mechanism can not be elucidated entirely; however it occurs com-monly by sudden inversion of foot, concurrently knee is at flexion and foot is at plantar flexion. Diagnosis can be made by determin-ing swelling and sensitivity increase at proximal tibia with comparing healthy side and radiological imaging techniques. Treatment is still a challenging and controversial issue and most of the cases are ap-proached conservatively; for selected cases, it is possible to carry out surgical stabilization. We have reported the case, an isolated disloca-tion of the proximal tibiofibular joint in a football player.

KeywordsProximal Tibiofibular Joint, Physical Examination, Radiography, Early Diagnosis.

Journal of Clinical and Analytical Medicine | 99

DOI: 10.4328/JCAM.236 Received: 21.03.2010 Accepted:14.04.2010 Printed: 01.09.2011 J Clin Anal Med 2011;2(3):99- 100

| Journal of Clinical and Analytical Medicine

İzole Fibula Başı Dislokasyonu / Isolated Dislocation of the Head of the Fibula

103

IntroductionIsolated dislocation of proximal tibiofibular joint is one of the rarely encountered and easily overlooked traumas in ER departments. Dislocation usually occurs during sports activation (i.e. football, horse-riding, parachuting, skiing) and is often accompanied by vari-ous bone fractures [1, 2]. Dislocation may take place in subluxation (type I) form as well as anterolateral (type II), posteromedial (type III), and superior (type IV) localizations. Injury mechanism can not be elucidated entirely; however it occurs commonly by sudden in-version of foot, concurrently knee is at flexion and foot is at plantar flexion [3-6]. Bulge and sensitivity increase are frequently deter-mined symptoms at physical examination. Anteroposterior (AP) and lateral (L) radiography and computerized tomography (CT) for selected cases whose diagnoses are undetermined may provide valuable clues leading towards the diagnosis [7]. Treatment is still a challenging and controversial issue and most of the cases are ap-proached conservatively; for selected cases, it is possible to carry out surgical stabilization. Clinical suspicion and early diagnosis at ER are effective for preventing long term complications [4, 6, 8]. In this report, we aimed to present an isolated proximal anterolateral tibiofibular dislocation experienced by a university student who fell down during a football game and admitted to ER with complaint of severe pain at his knee.

CaseA 22 year old male patient, suffering from right knee pain was ad-mitted to emergency department. There was a history of falling down while knee was at flexion and ankle was at inversion when he was trying to catch his sprinting rival in a football game. At physi-cal examination, painful hard swelling with size of approximately 3x4cm at lateral of right knee was palpated. (Figure 1, 2). There was no evidence of neurological deficit due to peroneal nerve injury. Besides, there was no other abnormality at physical examination of foot or ankle. AP and lateral radiography revealed anterolateral dislocation at right tibiofibular articulation. (Figure 3). CT was not required for diagnosis. As primary treatment, closed reduction and long leg walking cast was performed by orthopedic clinic. (Figure 4). Cast was removed after 4 weeks and he was referred to phys-iotherapy. Kneepad use was advised for whole treatment period. The patient was completely recovered by the end of three weeks of physiotherapy. Patient had no other complaint for three months follow-up and started to play football again after the end of three months.

Discussion Isolated dislocation of proximal tibiofibular articulation is uncom-mon and observed usually in sports branches which require active use of lower extremity. Typically, it is accompanied by ligament in-juries of knee articulation, fibula, tibia, femur and ankle fractures, knee dislocations, and peroneal nerve dysfunction. Most common type is anterolateral dislocation as observed in our case. The ac-cepted mechanism of dislocation of head of fibula is falling on the inverted foot accompanied with the knee flexed as the leg is vio-lently adducted by the weight of the body. This mechanism may occur in many sports types [2, 3, 6]. We consider that the same mechanism developed in our case as well. As a main diagnostic tool, AP/L radiography will usually be suffi-cient, but CT scan can be considered necessary for selected cases. In case of non-clear radiographic findings, comparison of both knees in the same position is essential. Main findings in radio-graphs can be listed as lateral fibula displacement which is obvious in anteroposterior view, increased distance between proximal tibia and fibula heads and head of fibula slide over on front of tibia, which results as an overlap of the fibula and tibia. The accompa-nying pathologies, diagnosed by the same radiographs are hidden fractures, avulsions, and abnormal calcifications [4, 7].Neglected dislocations can be resulted by chronic dislocations and degenerative changes. Long term complications can be eradicated by minimizing the delay between admission and intervention and closed reduction. Otherwise, surgical procedures (open reduction, fixation etc.) may be necessary. In such cases, chronic local pain is the primary symptom, as peroneal nerve can be damaged. Although our patient was an amateur sportsman; this type of complications can be much more important for a sportsman [1, 4, 6, 8].Considerably rare encountered proximal tibiofibular dislocation is an injury that can be treated very easily with conservative methods. This type of injuries can be easily underrecognized by emergency residents. Emergency residents should pay attention to knee trau-mas. It is mandatory to have an elaborated story, query trauma mechanism, carry out a comprehensive physical examination, and have a mindful radiologic evaluation. With this case report, we in-tended to remind this rarely encountered and easily ignored trau-ma.

1.Miettinen H, Kettunen U. Väätäinen U. Dislocation of proximal tibiofibular joint. A new method for fixation. A case report. Arch Orthop Trauma Surg 1999; 119: 358-359.2.Losifidis MI, Giannoulis L, Tsarouhas A. Isolated acute dislocation of the proximal tibiofibular joint. A case report. Orthopedics 2008; 31 (6): 605.3.Ogden JA. Subluxation and dislocation of the proximal tibiofibular joint. J. Bone Jt. Surg 1974; 56-A: 145-154.

4.Turco VJ, Spinella AJ. Anterolateral dislocation of head of the fibula in sports. The Am J Sports Med 1985; 13(4): 209-15.5.Thomason PA, Linson MA. Isolated dislocation of proximal tibiofibular joint. A case report. The Journal of Trauma 1986; 26(2): 192-195. 6.Sekiya JK, Kuhn JE. Istability of the proximal tibiofibular joint. J Am Acad Orthop Surg 2003; 11 (2): 120-128.

7.Keogh P, Masterson E, Murphy B, McCoy CT, Gibney RG, Kelly E. The role of radiography and computed tomography in the diagnosis of acute dislocation of the proximal tibiofibular joint. Br J Radiol 1993; 66: 108-111.8.Insall JN, Windsor RE, Scott WN, Kelly MA, Aglietti P. Surgery of the knee , 2nd edn. New York, Edinburgh, Madridi Melbourne, Tokyo, 1993; pp 1128-1130.

References

Figure 1. Inspection is one of the most important parts at physical examination.

Figure 2. Inspection is one of the most important parts at physical examination.

Figure 4. Closed reduction and long leg walking cast was performed

Figure 3. AP/L radiography showed dislocation

| Journal of Clinical and Analytical Medicine

İzole Fibula Başı Dislokasyonu / Isolated Dislocation of the Head of the Fibula

103

IntroductionIsolated dislocation of proximal tibiofibular joint is one of the rarely encountered and easily overlooked traumas in ER departments. Dislocation usually occurs during sports activation (i.e. football, horse-riding, parachuting, skiing) and is often accompanied by vari-ous bone fractures [1, 2]. Dislocation may take place in subluxation (type I) form as well as anterolateral (type II), posteromedial (type III), and superior (type IV) localizations. Injury mechanism can not be elucidated entirely; however it occurs commonly by sudden in-version of foot, concurrently knee is at flexion and foot is at plantar flexion [3-6]. Bulge and sensitivity increase are frequently deter-mined symptoms at physical examination. Anteroposterior (AP) and lateral (L) radiography and computerized tomography (CT) for selected cases whose diagnoses are undetermined may provide valuable clues leading towards the diagnosis [7]. Treatment is still a challenging and controversial issue and most of the cases are ap-proached conservatively; for selected cases, it is possible to carry out surgical stabilization. Clinical suspicion and early diagnosis at ER are effective for preventing long term complications [4, 6, 8]. In this report, we aimed to present an isolated proximal anterolateral tibiofibular dislocation experienced by a university student who fell down during a football game and admitted to ER with complaint of severe pain at his knee.

CaseA 22 year old male patient, suffering from right knee pain was ad-mitted to emergency department. There was a history of falling down while knee was at flexion and ankle was at inversion when he was trying to catch his sprinting rival in a football game. At physi-cal examination, painful hard swelling with size of approximately 3x4cm at lateral of right knee was palpated. (Figure 1, 2). There was no evidence of neurological deficit due to peroneal nerve injury. Besides, there was no other abnormality at physical examination of foot or ankle. AP and lateral radiography revealed anterolateral dislocation at right tibiofibular articulation. (Figure 3). CT was not required for diagnosis. As primary treatment, closed reduction and long leg walking cast was performed by orthopedic clinic. (Figure 4). Cast was removed after 4 weeks and he was referred to phys-iotherapy. Kneepad use was advised for whole treatment period. The patient was completely recovered by the end of three weeks of physiotherapy. Patient had no other complaint for three months follow-up and started to play football again after the end of three months.

Discussion Isolated dislocation of proximal tibiofibular articulation is uncom-mon and observed usually in sports branches which require active use of lower extremity. Typically, it is accompanied by ligament in-juries of knee articulation, fibula, tibia, femur and ankle fractures, knee dislocations, and peroneal nerve dysfunction. Most common type is anterolateral dislocation as observed in our case. The ac-cepted mechanism of dislocation of head of fibula is falling on the inverted foot accompanied with the knee flexed as the leg is vio-lently adducted by the weight of the body. This mechanism may occur in many sports types [2, 3, 6]. We consider that the same mechanism developed in our case as well. As a main diagnostic tool, AP/L radiography will usually be suffi-cient, but CT scan can be considered necessary for selected cases. In case of non-clear radiographic findings, comparison of both knees in the same position is essential. Main findings in radio-graphs can be listed as lateral fibula displacement which is obvious in anteroposterior view, increased distance between proximal tibia and fibula heads and head of fibula slide over on front of tibia, which results as an overlap of the fibula and tibia. The accompa-nying pathologies, diagnosed by the same radiographs are hidden fractures, avulsions, and abnormal calcifications [4, 7].Neglected dislocations can be resulted by chronic dislocations and degenerative changes. Long term complications can be eradicated by minimizing the delay between admission and intervention and closed reduction. Otherwise, surgical procedures (open reduction, fixation etc.) may be necessary. In such cases, chronic local pain is the primary symptom, as peroneal nerve can be damaged. Although our patient was an amateur sportsman; this type of complications can be much more important for a sportsman [1, 4, 6, 8].Considerably rare encountered proximal tibiofibular dislocation is an injury that can be treated very easily with conservative methods. This type of injuries can be easily underrecognized by emergency residents. Emergency residents should pay attention to knee trau-mas. It is mandatory to have an elaborated story, query trauma mechanism, carry out a comprehensive physical examination, and have a mindful radiologic evaluation. With this case report, we in-tended to remind this rarely encountered and easily ignored trau-ma.

1.Miettinen H, Kettunen U. Väätäinen U. Dislocation of proximal tibiofibular joint. A new method for fixation. A case report. Arch Orthop Trauma Surg 1999; 119: 358-359.2.Losifidis MI, Giannoulis L, Tsarouhas A. Isolated acute dislocation of the proximal tibiofibular joint. A case report. Orthopedics 2008; 31 (6): 605.3.Ogden JA. Subluxation and dislocation of the proximal tibiofibular joint. J. Bone Jt. Surg 1974; 56-A: 145-154.

4.Turco VJ, Spinella AJ. Anterolateral dislocation of head of the fibula in sports. The Am J Sports Med 1985; 13(4): 209-15.5.Thomason PA, Linson MA. Isolated dislocation of proximal tibiofibular joint. A case report. The Journal of Trauma 1986; 26(2): 192-195. 6.Sekiya JK, Kuhn JE. Istability of the proximal tibiofibular joint. J Am Acad Orthop Surg 2003; 11 (2): 120-128.

7.Keogh P, Masterson E, Murphy B, McCoy CT, Gibney RG, Kelly E. The role of radiography and computed tomography in the diagnosis of acute dislocation of the proximal tibiofibular joint. Br J Radiol 1993; 66: 108-111.8.Insall JN, Windsor RE, Scott WN, Kelly MA, Aglietti P. Surgery of the knee , 2nd edn. New York, Edinburgh, Madridi Melbourne, Tokyo, 1993; pp 1128-1130.

References

Figure 1. Inspection is one of the most important parts at physical examination.

Figure 2. Inspection is one of the most important parts at physical examination.

Figure 4. Closed reduction and long leg walking cast was performed

Figure 3. AP/L radiography showed dislocation

100 | Journal of Clinical and Analytical Medicine